When newly admitted medical students enroll in their respective programs, they participate in the cherished White Coat Ceremony, in which they eagerly vow to stop at nothing to help patients—to go above and beyond to provide the highest quality care to any and every individual who needs it. Though this aspiration is not overtly naïve, it is, perhaps, exceedingly optimistic. As training progresses, many students come to realize that the “best” care is not always the most accessible, and often does not make the most sense (from both financial and diagnostic standpoints). Medical school curriculums emphasize the consideration of “cost-effective care”—diagnostics and treatments that meet the necessary standards of care without spending unnecessary dollars. This approach certainly makes sense; after all, few physicians would find it sensible to order a costly MRI for a patient whose diagnosis is already obvious without it. However, this framework takes for granted a notion that, perhaps, deserves some thoughtful inquiry: how has our society so readily put a price on different tests and treatments—and, by extension, on life?
Of course, much of these costs stem from the prices of labor, materials, and expertise. However, we rarely wrestle with the underlying unease that comes with the fact of how we have put prices on any of these services at all. This is no one’s fault; there is a fundamental tension between limited health care resources and the priceless value of human life—a tension that no amount of wealth or means can overcome. The medical system is such that there can exist a contradiction between the care that is indicated and the care that would be most cost-effective; we want the best care for our patients, but do not have unlimited financial resources. How, then, do we forgive ourselves for placing a numerical valuation on the health requirements of others? After all, we are merely human—yet we must appraise the needs of our equally human patients.
Perhaps the beginning to this answer starts with recognizing that “value” is not solely a monetary term. High-value care might be sparing an exhausted elderly patient another battery of tests for a few more days, regardless of whether the results will change her medical management. It might be taking the extra time to look at a bump on a teenager’s arm, to ease his anxiety. It might be taking a patient’s perspective into account, and ordering the specific test he is asking for. In any respect, shifting the idea of “value” from a purely pecuniary definition to a more comprehensive one permits a more holistic notion of what is meant by “high-value care.” If we do only numerical calculations, our valuation is limited; we will do our patients justice only when we consider more than the financial.
Spending extra time with patients, getting to know them, and understanding their perspectives has been repeatedly shown to improve outcomes and build patient trust. What we have not considered, however, is the notion that these extra efforts might also have profound effects on the doctors who practice them. Approaching “value” as a multi-faceted entity—one whose definition differs for every single patient—is a personalized way to humanize the often “routine” practice of medicine. This view might help doctors, especially those in training, cope with the fact that different patients have different goals and be more understanding of questions and requests that are less traditional; it could encourage physicians to become more invested in patient care and redefine their conceptualizations of success.
Without a doubt, it is uncomfortable to consider high-value care from a monetary standpoint; it is unpleasant to ration resources and indirectly assign non-arbitrary values to human lives. This is one of the fundamental challenges of medicine. This profession has the capacity to save lives, but currently does so with great inequity. This task becomes less monstrous when we realize that, at the end of it all, we have the duty not to prolong life or protect funds at all costs, but to empower patients to achieve outcomes consistent with the World Health Organization’s definition of health: “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.”
Medical schools can plant these seeds early: curricular inclusion of teaching about financial toxicity—the term to describe problems that patients face related to the burden of payment— along with teaching about shared decision-making around individual values and goals have the potential to shape physician engagement with individuals who might need extra support3. And while clinicians can do right by their patients by being conscious of costs, they can do even better by including other, non-monetary components in the value calculation of what determines whether care is “worth it.”
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